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I m � APPLICATION FO-i PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCfCTON, CA Telephone (209) 466-6781 i4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pnd the Rules and Regulations of the San Joaquin Locale Health District, p / � Job Address W City Lot Size �z>f/ PM Owner's Name ddress ''` t '' Phone _ 4 COnfraCtOr ■ �. tldress""'fL�icEnse}E�o W T /y Phone _c �� TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑l SYSTEM REPAIR ❑ OTHER ❑ ., t DISTANCE TO NEAREST: SEPTIC, TANK SEWER LI S DISPOSAL FLD., PROP.LINEA ' FOUNDATION AGRlCULT R ELL'S , OTHER WELL PITS/SUMPS ---•!INTENDED USE TYPE OF WELL � PROBLEM AREA S7`RUCTION't'PECIFICATIONS""""' ' ❑ Industrial 3 °' -❑--Oper?'8oitom'`"" "C] Manteca f Dia. of Well ExcaGation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy F Type of Casing " .Specifications i 7 Public F1 Other ❑ Delta Depth of Grout Seal11 ;Type of GPout I I Irrigation Approx. Depth I ] Eastemr Surface Seal Installled by _ Repair Work Done ❑ Type of Pump H; t State Work Done Well Destruction ❑ Well Diameter, .,,Sealing Material ;top Depth `Filler Material..f[3elow 50'} ` TYPE OF SEPTIC WORK: NEW INSTALLATION i. RI-PAIR/ADDITION'l I i DESTRUCTION l I (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_k"'Commercial_ Othef " I Number of living units: Number of bedrooms, N3 _,_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit # p Y– No. Compartments `. PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest! well Foundation_ ). Property Line tt LEACHING LINE ❑ No. & Length of lines Total length/site' FILTER BED ❑ Distance to nearest: t Well �p Foundation ""'P' i –l--I��a— �.t�_ Property' s f f ��• 4 1 Y SEEPAGE PITS ( I Depth t Size _ Number r SUMPS Cl Distance to nearest: Well Faundatio Property Line DISPOSAL PONDS ❑ 4 # : hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ii Home owner or licensed agent's signature certifie"s the following: "I certify that in the performance of the work for which this Permit is issued, I shall not t. employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature •-_. certifies the following:_'I,certifyFthat.in the,performance of,the work for which.this-per"tJs issued;.)shall-employ.persons subject-to•workman'-s-compensa- tion laws of California." The applicantlust call f=pe spections" Complete drawing on reverse side. i Signed X Title: r- bate: FOR DEPARTMENT USE ONLY r Application Accepted by Date �grea 1 r E ' f Pit or Grout Inspection by Date Final Inspection by -Date Additional Comments: 4 € ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .6 't Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOU T REMITTEDCASH RECEIVED SY DATE PERMIT NO. '+.EH 13-24 iREV.1/n 51 O \k EH t4-ZB � _ b